Homebuyer Set Up and Completion Form

HOME Program (For single and multi-address activities)

Check the appropriate box:
Original Submission Change Owner’s Address
Ownership Transfer Revision / Name and Phone Number of Person Completing Form:

Set Up Homebuyer Activity:

A. General Information.

1. Name of Participant: / 2. County Code: / 3. IDIS Activity ID Number: / 4. Activity Name:

B. CHDO Information. (Only if applicable)

1. Is funding limited to CHDO Operating (CO) or CHDO Capacity Building (CC)? Y/N:
(If Yes, STOP. DO NOT FILL OUT THIS FORM.) / 2. If this is a CHDO activity (funded with CR), is the CHDO acting as (check one):
(1) Owner (2) Sponsor (3) Developer
3. Is this a CHDO Loan? Y/N:
(If Y, answer Item 4.) / 4. Is the activity going forward? Y/N:
(When Y, fill out the rest of the form. If N, Sections ?? are not needed.)

C. Activity Information.

1. Activity Type (check one):
(2) New Construction Only (4) Acquisition & Rehab
(3) Acquisition Only (5) Acquisition & New Construction
1. Homebuyer’s Name (optional): / 2. Homebuyer’s Street Address:
3. City: / 4. State: / 5. Zip Code: / 5. Estimated HOME Units: / 6. Estimated HOME Cost:
7. Loan Guarantee? Y/N:

D. Developer Information. (Only applicable if this is a multi-address activity)

1. Developer Type (check one):
(1) Individual (4) Not-for-Profit
(2) Partnership (5) Publicly Owned
(3) Corporation (9) Other / 2. Developer’s Name:
3. Developer’s Street Address:
4. City: / 5. State: / 6. Zip Code:

Complete Homebuyer Activity:

E. General Information. (Same as set up)

1. Name of Participant: / 2. County Code: / 3. IDIS Activity ID Number: / 4. Activity Name:

F. Activity Information. (Sections F, G, and H are to be filled out for each property address. If this is a multi-address activity, make copies of this form so that each address has separate F, G, and H information.)

1. Activity Type (check one):
(2) New Construction Only (4) Acquisition & Rehab
(3) Acquisition Only (5) Acquisition & New Construction / 2. Property Type (check one):
(1) 1-4 Single Family (3) Cooperative
(2) Condominium (4) Manufactured Home / 3. Total Completed Units:
HOME-assisted Units:
504-accessible Units:
4. Homebuyer’s Name (optional): / 5. Homebuyer’s Street Address:
6. City: / 7. State: / 8. Zip Code: / 9. Purchase Price: / 10. Value After Rehab (only applicable for Acquisition/Rehab activities):

G. Activity Costs.

1. HOME Funds (Including Program Income)

a. Property Costs

(1) Amortized Loan / $
(2) Grant / $
(3) Deferred Payment Loan (DPL) / $
(4) Other / $

b. Downpayment Assistance

(1) Amortized Loan / $
(2) Grant / $
(3) Deferred Payment Loan (DPL) / $
(4) Other / $
c. CHDO Loan / $
Total HOME Funds [a + b + c] / $

2. Public Funds

(1) Other Federal Funds / $
(2) State/Local Funds / $
(3) Tax Exempt Bond Proceeds / $
Total Public Funds [(1) + (2) + (3)] / $

3. Private Funds

(1) Private Loans / $
(2) Owner Cash Contribution / $
(3) Private Grants / $
Total Private Funds [(1) + (2) + (3)] / $
4. Activity Total (Sum All Totals) / $

H. Household Characteristics. (Refer to code below where applicable)

/
Household
/
Unit # / # of Bdrms / Occupant / % Med / Hispanic?
Y/N / Race / Size / Type /
Assistance Type
/ Total Monthly Rent
1. Homebuyer Counseling? (check one):
(1) No Counseling (3) Post-counseling
(2) Pre-counseling (4) Both / 2. First-time Homebuyer? Y/N: / 3. FHA Insured? Y/N:
4. Lease Purchase? Y/N: If yes, date of agreement:

Page 2 of 3 Revised (2/04)